The Long Journey Home

by Sally Ann Flecker

No one should see the things they have seen, these young men and women who have gone off to war.

No one should see children horribly wounded, people maimed, bodies bearing unmistakable signs of unimaginable torture. No one should see the face of a comrade-in-arms, a friend, vivid with life one minute and gone in the instant it takes an IED to explode. No one should see.

And yet those who fight in Afghanistan or Iraq have seen such things, and the experience may cast a long shadow over their lives. They can come back home, hold on tight to their wives or husbands. They can come back home and hug sons and daughters, cradle babies born while they were gone. They can come back home and pick up their lives. But not all warriors can return—not to who they were before they saw the things no one should see.

But still, they hope. Families and friends, neighbors and wellwishers, the soldiers themselves all hope in their heart of hearts that they can step back into the lives that used to fit them so well.

And some do, after a fashion. But many cannot. They drop to the floor at the sound of a car backfiring, panic if their spouse fails to pick up the phone when they call, refuse to go to crowded places. They are cold to the people who love them. They argue, explode in anger over inconsequential things, drink. They'd give anything for a good night's sleep, but sleep is hard to come by and doesn't stay long enough.

There's a name for this. Soldiers returning from the Civil War were said to be suffering from "soldier's heart." In the 20th century they were shell-shocked or had combat fatigue. Today, when veterans of the wars in Iraq and Afghanistan have long-term difficulties shifting back to civilian life, the diagnosis is post-traumatic stress disorder, or PTSD.

PTSD is formally on the books as a psychological condition. But mind and body work together, so PTSD is very much the body's physical reaction to the trauma of war as well. The emphasis on "physical" is an important point for retired Army psychiatrist Charles Hoge '80, who wrote Once a Warrior Always a Warrior (GPP Life, 2010) to help soldiers with the transition from a hostile environment to home.

For returning soldiers, there's a paradox at the heart of PTSD, Hoge believes. The symptoms that affect their ability to enjoy life back home, have meaningful relationships, or hold down a job are often the flip side of the reflexes that kept them alive in a war zone. "We place unrealistic expectations on warriors in thinking they can just snap out of these reactions when they come home, when, in fact, they don't stop being a warrior," Hoge says. It's not just their minds that can't let go. It's their bodies.

Soldiers train relentlessly so that their minds don't get in the way of their bodies. They develop an extreme sense of situational awareness, for instance, so that they are ready to respond instantly to any threat. "Being hyperalert and startling quickly are life-saving in the combat environment," Hoge says. When those reactions continue at home, though, they interfere. Hit the ground because there is a loud noise outside your workplace and coworkers will wonder what's wrong with you. But the body is doing what it's been trained to do.

"Just think about combat driving," Hoge says. "There is a fairly aggressive way of driving to try to avoid explosive devices. You change lanes. You avoid certain obstacles. If you see trash on the side of the road, you move quickly around it." Soldiers may come home and instinctively drive the same way. Going through an underpass, they might suddenly change lanes because the enemy used to drop explosives down on them from above. Or when they see a dead deer on the side of the road, they'll swerve to put as much distance as they can between themselves and the animal, because the enemy used to rig corpses (both animal and human) with explosives. "I've known soldiers who end up in a ditch because they swerved out of the way," he says.

Being able to function on little or no sleep is another aspect of hyperalertness. If soldiers' sleep cycles don't return to normal when they get home, they'll find themselves awake in the middle of the night, and may self-medicate with alcohol or drugs. This may lead to aggression and other risky behaviors. In fact, many cases of abuse are grounded in a desperate attempt to get some much-needed sleep.

Anger is another double-edged sword. In normal life it's often considered a negative emotion. Not so in the battle zone. "It is like a shot of Ritalin," Hoge says. "It helps you focus on the mission, achieve your objective, tune out pain awareness, overcome sleep deprivation, push your muscles to the limit that you didn't know was possible before. Warriors get used to having higher levels of anger in that environment." But when they come home, that higher level of anger is discomforting to everyone.

Similarly, soldiers at war can't afford to grieve fallen team members, because grief impairs their ability to focus on the mission. Back at home, this emotional numbness can make it hard to negotiate relationships. Spouses may feel shut out and unloved. "There is an adaptive quality to numbing," Hoge points out. "But when it persists and interferes with functioning, then it goes into the realm of the PTSD disorder."

As the former head of mental health research at Walter Reed Army Institute of Research, Hoge is one of the leading experts on PTSD experienced by soldiers. "I started a very small research program in 2000," he says. "We had just barely gotten that off the ground when 9/11 hit. Then we were just running after that." As the wars in Iraq and Afghanistan unfolded, Hoge directed research on the psychological and neurological consequences for soldiers. Most of his work took place safely 6,000 miles away. But in 2004 he was deployed to Iraq as part of a research team to investigate the delivery of mental health care in the war zone. There, on the operating bases, he experienced the daily threat of rocket fire screaming overhead. But even worse were the risks involved any time the team had to travel from one location to the next, whether on the road or by Blackhawk helicopter.

Hoge received a lot of attention in 2004 with the publication of research that documented a significant incidence of depression and PTSD in troops returning from combat duty. Even more important, the study revealed that the service members who stood to gain the most from treatment never sought help because of the stigma associated with mental health care. Soldiers were concerned that their peers would lose confidence in them, their leaders would treat them differently, and their careers would be undermined. "The problem is that stigma is very pervasive in society. We are dealing with mostly young men who don't seek mental health care anyway," Hoge says. Some think that mental health care doesn't work or is only a last resort.

This research "put the topic of stigma on the map," Hoge says. And as a result, Department of Defense and Veterans Administration leaders started to take the problem seriously and encourage soldiers to get the help they need through a variety of programs, including screening, education and training, and increased resources for mental health care.

Hoge may understand more than most what is happening to soldiers returning from war. But it's not, he'll readily admit, something he could have forecast when he was a student at Sarah Lawrence. He was a flutist and studied mostly humanities and music. Had you told him then that he would have a career in the Army, he would have scoffed.

He only became interested in medical school in his second year at Sarah Lawrence. After earning his medical degree from the University of Maryland, he followed his curiosity, starting with infectious diseases, tropical medicine, and public health. He's been a "disease detective" at the Centers for Disease Control in the Epidemic Intelligence Service program, where he investigated emergency public health outbreaks. He transferred to the Army to work at a highly regarded field studies lab in Bangkok, helping to identify a new cause of chronic traveler's diarrhea in Nepal and working with US troops when they came over to do field exercises with the Thai army.

"I didn't have any inkling that I would ever stay with the military beyond a wonderful four years there," he says. But when a previous interest in mental health started to bubble up to the surface, he chose a residency in psychiatry at the Walter Reed Army Hospital.

Over the course of his military career, he oversaw tens of thousands of surveys and focus groups with troops before, during, and after deployment. He developed training materials based on this research and treated service members, veterans, and their families at Walter Reed Army Medical Center. Hoge is most proud of the research on PTSD, as well as his work on mild traumatic brain injury, which was used to change government policy and to improve services in the Department of the Army.

Charles Hoge '80 and his wife Charise '80 at home in Bethesda, MarylandHoge officially retired from the army in 2009. He is married to Charise McFadden Hoge '80, who is a dancer and yoga instructor and has a book of her own, A Portable Identity: A Woman's Guide to Maintaining a Sense of Self While Moving Overseas. The couple met in their first month at Sarah Lawrence. They have two daughters, ages 23 and 17. The family has a cabin in West Virginia where they like to go in their spare time. But Hoge confesses that he's a workaholic. He continues in his civilian life to be involved at Walter Reed's research unit, developing resilience training programs to help returning soldiers become more aware of how their battle skills relate to reactions back home.

The transition home can be fraught with peril, no matter how happy soldiers are to return. The number of troops who commit suicide keeps rising. According to one report, more members of the service died in 2009 as a result of accidents and high-risk behaviors than at war. Domestic abuse increased by 177 percent in six years.

Life may actually feel more difficult at home because of everyday demands and minutiae. Kids need attention. Cars have to be repaired. Bills must be paid. On the other hand, Hoge says, "Over there, it is very simple. You know exactly what you have to do every day, even though it is completely chaotic and insane. A lot of soldiers get home and say they want to go right back."

The truth is, no one knows why one soldier returns from war so affected by the experience that it rises to the level of PTSD and another does not. But Hoge's insight into PTSD as a physiological condition may go a long way toward enabling those who suffer to seek support.

Hoge wrote Once a Warrior Always a Warrior to help all who are trying to navigate the murky waters of the transition home. "PTSD is a spectrum. Everybody has reactions where they're affected by the war zone experience," says Hoge. "They don't necessarily have a serious impairment of functioning that rises to the level of PTSD, but there are still other challenges." Hoge's goal was to convey useful medical information and resources for soldiers as well as their families. He knew that in order to reach his intended audience, he had to find a voice and approach that would resonate with their own experience. Judging from the many e-mails he's received following Once a Warrior's publication, he's done just that.

One complimented him on being the most compassionate PTSD writer she'd ever come across. A Vietnam vet said he felt like the book was about his life and trials during the 30 years since he returned from Southeast Asia. Former senator and wounded veteran Max Cleland described the book as "the guide to surviving the war back here."

One letter, from a soldier who returned from Iraq, was heartbreaking and hopeful at the same time. He talked about how he found himself at the lowest point in his life, so much so that even though he had never believed in suicide, he understood why so many servicemen had chosen to take that step. He said the introduction to the book screamed to him of everything he was going through, but it also gave him the motivation to keep going and the comfort of knowing he was not alone.

And that's Hoge's very hope—that his book will speak to those who have returned and help them to finally find their way back home.

Sally Ann Flecker is a freelance writer and writing coach living in Pittsburgh. She's written on a diverse array of topics for universities around the country.